CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
A CITY OF RIALTO
CLAIM FOR DAMAGES 2023 APR - 4 AMI: 12
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2).
3.READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
AnthonY R RODRIGUEZ
FULL NAME
DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
RIA to CA 92376 SAne
L
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE SAMe
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: — 4/1/2023 _ TIME: 2 LAMARM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
3. HOW DID DAMAGE OR INJURY OCCUR?
eWINghoMeFRIM CHuRcHHit A Pot
Hole thatwas, ON, the stReet NORtH
EucalyPtuS EKING
4. WERE POLICE AT THE SCENE? YES ANO WERE PARAMEDICS AT THE SCENE? DYES DAO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
Pot HolE oNtHe stReet
RIAItO
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 13/87 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
OT ATRE FIX, tON 4/2/23 Amounts /3/87
Item/Date:
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $13/87 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 4/3/2023 13/87
Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $_ 13/87
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Anthony RRoDRiguez
+ →NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NoNe voNe
ADDRESS: ADDRESS:
TELEPHONE: _) TELEPHONE: |)
DATE: TIME: DATE: _ TIME: • AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X".
• NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB FUCA Y PtusAve
PARKWAY
SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
ISRAEK/OR DECLAREVANÉR RENALTV AE REP WURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
ANTHONY 4/3/2023
TYPE OR PRINT NAME DATE
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 Hires LES SCHWAB 6251 Sierra Ave Store: 570
Fontana, CA 92336
9094286769 Invoice: 57000301323
Salesperson: Jesus P
Work Order#: 57000301303
ARD 301931
Customer Information
Vehicle Information
Customer ID: A057030767
Vehicle: 2022 TOYOTA COROLLA
Name: ANTHONY RORIGUEZ
Color:
Address:
Mileage: 23,156
City, State, Zip: FONTANA, CA 92336 License: 2023 APR -4 Phone:
CITY CLERH RECEIVED CITY OF RIAL
Comments: CUSTOMER TOOK TIRE WITH HIM.
AM I
Les Schwab Invoice
Qty Product Code Product Description Price/ea
FET Amount
1 638799 225/40R-18XL 92W VELOZZA ZXV4
$104.99 $0.00 $104.99
1 13718 WHEEL SPIN BALANCE
$16.99 $0.00 $16.99
Parts Subtotal: $104.99
Labor Subtotal: $16.99
Sales Tax: $8.14
Tire Fee: $1.75
Invoice Total: $131.87
Payment Method: CASH $140.00
CASH BACK ($8.13)
DOT: Tire(s) has been electronically registered.
Wheel Position: LF, PERALTA
Notes To Review 1 NEW LF. DAMAGED TIRE DUE TO POTHOLE. NO VISUAL CONCERNS With Customer:
Service Checklist:
Visual Tire Inspection | Comments: 8/32 ALL
Tire Pressure Check | Comments: 35 PSI
Visual Wheel Alignment | Comments: EVEN WEAR
Front End Component Check | Comments: TIGHT
Visual Shock/Strut Inspection | Comments: NO LEAKS LF
Visual Brake Inspection | Comments: 8MM LF
Remember to rotate your tires every 5,000 miles for maximum mileage - and it's freel Les Schwab electronically registers your tire purchase with the tire manufacturer at no charge to you, in accordance with NHTSA's tire registration requirements.
Invoice Date/Time: 04-03-2023 12:03 PM Page 1 of 2
CITY OF RIALTO
2023 APR - 4 AMM: 12
CLERI
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